Pneumothorax in Human Immunodeficiency Virus Infected

Original Articles
Pneumothorax in Human Immunodeficiency
Virus Infected Patients
José A.Cabrera-Cordero,a Radamés I. Adefna-Pérez,b Armando Leal-Mursulí,b Juan Antonio Castellanos-González,b
Francoise T. Izquierdo-Lara,b and Suset Cabrera-Alfonsoa
a
Servicio de Cuidados Intensivos, Hospital Clínico Quirúrgico Docente Dr Miguel Enríquez, Ciudad de la Habana, Cuba
Servicio de Cirugía General, Grupo de Cirugía Torácica, Hospital Clínico Quirúrgico Docente Dr Miguel Enríquez,
Ciudad de la Habana, Cuba
b
Abstract
Introduction. The respiratory system still continues
to be a common place which deteriorates in HIV patients.
Among the signs and symptoms, is the occurrence of
a pneumothorax due to trauma and infections and is a
cause of aggravation for these patients. The present
study attempts to identify and characterise the behaviour
of a group of variables in HIV patients with this
complication.
Material and method. An observational, descriptive
case series study was carried out.The desired variables
were obtained from clinical records.
Results. Of the total number, 91.67% were males, and
the mean age was 32.17 years. The main causes of
pneumothorax were infections, particularly due to
Pneumocystis jirovecii and deep venous catheterisation.
A persistent statistically significant air leak was present
in 33.3% of patients and two cases of pleural sepsis.
Four patients died, all with acute respiratory failure and
bacterial bronchopneumonia.
Conclusions. The majority were males in the third
decade of life, AIDS patients. The main causes of the
pneumothorax were infections and catheterisation of
the subclavian vein. Immunodepression played a
significant prognostic role in the progression and
outcome of the patient. Minimum pleurotomy continues
to be the first treatment option in these patients, due
to their precarious general state which contraindicates
a major procedure.The most frequent complication was
the persistent air leak, being a significant indicator of
a poor prognosis in the progress of these patients.
Correspondence: Dr. R.I. Adefna-Pérez.
Santa Catalina 162 e/c Heredia y Saco.
CP 10500. Ciudad de la Habana. Cuba.
E-mail: radames@infomed.sld.cu
Manuscript accepted April 8, 2008; accepted for publication May
8, 2008.
Causes of death such as acute respiratory failure and
bilateral bronchopneumonia prevailed.
Key words: HIV. Pneumothorax. Pneumocystis jirovecii.
Pleurotomy. Venous catheterisation. Complications.
NEUMOTÓRAX EN PACIENTES INFECTADOS
CON EL VIRUS DE LA INMUNODEFICIENCIA
HUMANA
Introducción. El sistema respiratorio continúa siendo un sitio común de deterioro en los pacientes con
el virus de la inmunodeficiencia humana (VIH). Entre
sus manifestaciones está el neumotórax por causas
traumáticas e infecciosas y que es una causa de
agravamiento para estos pacientes. El presente estudio pretende identificar y caracterizar el comportamiento de un conjunto de variables en pacientes con
VIH con esta complicación.
Material y método. Se realizó un estudio observacional descriptivo del tipo de serie de casos. De los
registros clínicos se obtuvieron las variables deseadas.
Resultados. El 91,67% eran varones, la media de
edad fue 32,17 años. Las principales causas del neumotórax fueron infecciosas, particularmente neumonía por Pneumocystis jirovecii y cateterismo venoso
profundo. El 33,3% de los pacientes presentó fuga de
aire persistente (con significación estadística) y 2 casos, sepsis pleural. Fallecieron 4 pacientes, todos
con insuficiencia respiratoria aguda y bronconeumonía bacteriana.
Conclusiones. Fueron mayoría los varones en la
tercera década de la vida, enfermos de sida. Las principales causas de neumotórax fueron las infecciosas
y la cateterización de la vena subclavia. La inmunodeficiencia tuvo un papel pronóstico relevante en la
evolución y el desenlace del enfermo. La pleurostomía mínima sigue siendo la primera opción de tratamiento en estos pacientes debido a un precario estaCir Esp. 2008;84(4):221-5
221
Cabrera-Cordero JA et al. Pneumothorax in Human Immunodeficiency Virus Infected Patients
do general que contraindica un proceder mayor. La
complicación más frecuente fue la fuga de aire persistente, que fue significativa como factor de mal
pronóstico en la evolución de los pacientes. Prevalecieron, como causas de muerte, la insuficiencia respiratoria aguda y la bronconeumonía bacteriana bilateral.
2. To identify the etiology of the pneumothorax and the
therapeutic care for the patients in the group.
3. To determine some of the complications and causes
of death in the group studied.
4. To identify the bad prognosis factors in the development
of the patients studied.
Palabras clave: VIH. Neumotórax. Pneumocistys jirovecii. Pleurotomía. Cateterismo venoso. Complicaciones.
Material and Method
Introduction
In 1981, the frequent appearance of Pneumocystis jirovecii
pneumonia (previously Pneumocystis carinii) in homosexual
males led to the description and recognition of AIDS and to
the subsequent identification of the human immunodeficiency
virus (HIV). Today there are 40 million people affected by
the virus worldwide, a number which is in constant increase.1,2
The Caribbean is the second most affected region in the
world, although Cuba has a prevalence of less than 0.2%.3
Cuba is an exception to the global figures due to the major
Cuban Programme which is in place to combat this epidemic.
Free access to antiretroviral therapies is one of the many
important aspects4 offered by the programme. Currently the
HIV epidemic is on the increase in Cuba, although on a
reduced scale. The annual number of cases has increased
almost 5 times between 1995 and 2000.5
The respiratory system continues to be the worst affected
area in people with HIV. In more than 90% of autopsies
carried out on patients who died from HIV, pulmonary
disorders had played a significant role in the process leading
up to death.6,7 The appearance of pneumothorax is a part
of this respiratory morbidity. The main causes are trauma
and infections originating from tuberculosis and atypical
mycobacteria, bacterial pneumonia, and ruptures of septic
pulmonary infarcts.8 However, the most important cause of
pulmonary infection is P jirovecii which causes pulmonary
destruction and cavitation with the development of blisters.
Pneumothorax develops due to the rupture of a subpleural
cavity as a cause of necrosis of the area, leading in turn to
the patient’s deterioration.
Since the beginning of the epidemic our hospital has been
majorly linked to the care of HIV/AIDS patients with surgical
illnesses and it has established itself as the reference centre
for this disease. As the number of affected people increased,
more people were admitted to hospital with HIV and
pneumothorax which made us realise that the therapeutic
and medical-surgical evolution of the disorder was radically
different to the development of pneumothorax in
immunocompetent patients.We did not know enough about
the subject which is what prompted us to go on to analyse
it further so as to find answers.
Our general objective was to characterise the behaviour
of a group of selected variables in HIV-positive patients
diagnosed with pneumothorax.The specific objectives were:
1. To describe the clinical, epidemiological, and
immunological characteristics of the patients studied.
222
Cir Esp. 2008;84(4):221-5
Descriptive, observational case studies were carried out
on HIV positive patients with pneumothorax who were
admitted to the intensive care unit of the Surgery-University
Hospital Miguel Enriquez between January 1, 2000 and
December 31, 2006.
The criteria considered were: patients infected with HIV,
over 15 years of age, with pneumothorax of any etiology
whether accompanied by pleural effusion or not.
Selected variables: gender, age, time between infection
with HIV and pneumothorax, previous clinical status,
opportunistic diseases, immunological state at the time of
pneumothorax and its causes, operations carried out,
postoperative complications, mortality and cause of death.
Two patients were excluded from the tests as they had
traumatic pneumothorax from an injury caused by a bladed
weapon.
Results
Over the period of time studied, 12 HIV positive patients
with pneumothorax were admitted to hospital and therefore
met the criteria for the test. This represents 6.89% of the
total of HIV-positive patients admitted to hospital during the
same period of time.
Ninety-one point six percent (11) of patients were male.
The average age was 32 (range, 22-52).Ten patients (83.3%)
had AIDS and 2 (17.7%) were seropositive. The average
time of HIV infection was 5 years. Overall, the patients studied
presented 29 opportunistic illnesses, 9 of which were
respiratory in 75% of cases.
Of the 12 patients, 6 had secondary spontaneous
pneumothorax and 6 had traumatic pneumothorax due to
central venous catheterisation. Of those, 10 patients
presented a pneumothorax of 70% or more, and 2 cases
had of 40%. A minimum pleurectomy was carried out for all
of them, 8 were high and 4 were low. The procedure was
repeated in 2 patients due to obstruction of the chest tube.
Most patients had CD4 T-cell counts between 200 and
459 cells/µL (n=7; 58.3%). Seven postoperative complications
were recorded in this group; 5 patients survived; and 2 died.
There were 5 patients in the group with a CD4 T-cell count
of less than 200 lymphocytes (41.66%), 2 postoperative
complications, 3 patients survived, and 2 died (Table 1).
Persistent air leaks were the most serious postoperative
complications in 4 patients; which was very related to the
death of all 4, with an average of 10 days of aspiration, and
related to this, pleural sepsis in 2 of the deceased.
Other complications were repeated pulmonary collapse,
obstruction of the tube chest, and subcutaneous
emphysema in 2 patients. Average pleural aspiration was
6 days (Table 2).
Cabrera-Cordero JA et al. Pneumothorax in Human Immunodeficiency Virus Infected Patients
TABLE 1. Concentration of CD4 T-Lymphocytes and Patient’s Development
CD4 T-Lymphocyte Count
200-499 Cells/µL
<200 Cells/µL
Total
Development
No. (%)
Average
Postoperative
Complications
Survived
Deceased
7 (58.3)
5 (41.6)
12 (100)
359
102
—
2
7
—
5
3
8
2
2
4
Of the 12 patients studied, 4 died; lethality was 33.3%. It
was seen that acute respiratory insufficiency due to bilateral,
bronchial, bacterial pneumonia was the main cause of all
the deaths, aggravated by other factors such as pulmonary
fibroemphysema in 1 case, bronchial asthma in another,
and purulent pleurisy in the remaining 2 cases.
There were 7 postoperative complications recorded in the
group of deceased subjects and 5 in those who survived.
TABLE 2. Relationship Between Postoperative Complications
and Death
Complications
No. (%)a
Deceased, No. (%)b
Persistent air leak
Pleural empyema
Persistent pneumothorax
Obstruction of tube chest
Subcutaneous emphysema
Death
4 (33.3)
2 (16.6)
2 (16.6)
2 (16.6)
2 (16.6)
4 (33.3)
4 (100)
2 (50)
—
—
—
—
a
Refers to the total number of patients.
Refers to the total number of deceased.
b
Discussion
The appearance of pneumothorax, despite being a known
complication in patients with HIV, is not a frequent occurrence
over the course of the illness, as it only occurs in 2%-5% of
the overall total of cases.10-12 The advances made in antiviral
therapy have helped to decrease this eventuality.13,14 Our
study included 12 patients, although pneumothorax could
only be directly attributed to respiratory disease in 6 of them.
The figure of hospital admissions due to pneumothorax in
our investigation is similar to other reports.11,12 The values
oscillate between 2% and 6% of those hospitalised.11 The
relationship of gender-age variables and the appearance
of pneumothorax coincide with the actual epidemiology of
HIV infection in our county, with the highest frequency
occurring in males aged between 30 and 49 years old. It is
precisely in this age group where there is a higher risk of
infection by the virus and, often these individuals become
ill with AIDS early in their lives.3
There are not many studies which emphasise the
significance of traumatic pneumothorax, and iatrogenic
pneumothorax in particular, in HIV infected patients with
severe disorders who undergo aggressive diagnostic
techniques and therapies carrying a high risk of mortality,
in comparison with patient groups who are not affected by
these disorders. In our study there was an equal number of
patients with traumatic pneumothorax and spontaneous
pneumothorax. The spontaneous pneumothorax which
occurred was always secondary, mainly due to opportunistic
respiratory disorders, which occur when HIV infection is
advanced. Necrosis, cavitation and rupture produced by
many of the germs are due to this. Traumatic or iatrogenic
pneumothorax always resulted from subclavian puncture.
Although this is a known complication with this approach,15
the incidence tends to be higher in these cases basically
due to severe dehydration, which requires a more demanding
technique, and, above all, a diseased lung, since it is more
susceptible to becoming lesioned. It is important to point
out that there were no cases of tuberculosis, which is one
of the problems that does frequently affect AIDS patients.16,17
Previous use of parenteral or inhaled drugs was not identified
either, which is usually associated with the development of
pneumothorax.
The patients’ immune state, calculated using the CD4 Tlymphocytes value,18 attempts to relate a weak immune
system with the actual appearance of pneumothorax, the
patient’s progress and the end result of the process. There
is an indirect relationship between immune deficiency and
incidence of pneumothorax which is relative to the
appearance of opportunistic respiratory infections which are
undoubtedly favoured by immunodeficiency. However, the
implications are strongly indicative that development implies
a relationship between pneumothorax and immune
depression. In our work, although definitive conclusions
cannot be reached due to the small number of patients who
were studied, most of the complications occurred in those
patients in the group with higher immunodeficiency and the
higher percentage of deaths also occurred in this group.
Not only this, but the complications were also more serious
for this group, such as pleural empyema, strokes, and
persistent air leaks. All of this could mean that pneumothorax
is produced in an advanced stage of the illness, both for the
group with spontaneous pneumothorax and the iatrogenic
group, and the state of the lung, regardless of the cause of
the pneumothorax, is an important variable in development
after surgical treatment.
The most serious occurrences directly related with the
illness were persistent air leaks, defined as air leaks which
last for more than 7 days. Persistent air leaks occurred more
frequently in patients with HIV than in patients not infected
with the virus, both in the spontaneous and traumatic
pneumothorax groups. This higher frequency is related to
the state of the underlying pulmonary parenchyma which
is generally deteriorated, inflamed, friable, or necrotic due
to the infectious process, which then complicates achieving
re-expansion and successful aerostasia.
Cir Esp. 2008;84(4):221-5
223
Cabrera-Cordero JA et al. Pneumothorax in Human Immunodeficiency Virus Infected Patients
It is known that pneumothorax in patients with HIV have
a high level of therapeutic failures, which leads to certain
options which have been validated in other situations, such
as puncture or suction of the pneumothorax,19 particularly
in the iatrogenic pneumothorax, not being recommended
here.The initial indicated therapeutic intervention will always
be early and forceful; consisting of minimum pleurotomy
and remission in specialised centres.20 The immediate
administration of a sclerosis agent into the thoracic drainage
tube is another option for patients who want to avoid more
serious surgery at all costs due to the higher surgical risks.20,21
The differences in development that exist between
spontaneous pneumothorax and those produced by invasive
manoeuvres are known: the first type requires longer drainage
time for recuperation.22 In this group the suction time was
always more in our group, also more complications and
higher lethality occurred.
If pulmonary re-expansion is not achieved, other treatments
should be tried. A second pleurotomy could be an option,
especially when tube obstruction is suspected, but generally
this is also insufficient. In these cases, it is advisable to use
a videothoracoscopy to which a chemical irritant is added
to favour pleurodesis, especially asbestos-free, sterile talc
which is the cheapest and most efficient of the available
sclerosis agents.21,23 Although a recent systematic
assessment24 puts forward a long-term reoccurrence index
of pneumothorax which is 4 times higher with
videothoracoscopy in comparison with open surgery, if these
results were certain, and without considering the possible
methodological errors of the study in question,25 this may
not be a limitation for patients with a low survival index. If
the problem is a pleural infection or even more serious, the
appearance of bronchial-pleural fistula, prognosis is more
serious. In general, thoracotomy is impractical given the
severity and weakness of the patient. Less aggressive
procedures such as the Eloesser window for pleural
empyema or use of the Heimlich valve for prolonged air
leaks26 are alternatives to the usual treatments. In our patients,
a thoracotomy was never carried out as the general state
of the patients impeded such a procedure, even as a last
resort. We always tried drainage with a chest tube.
In the literature consulted, mortality was between 30.8%
and 34%,12,17,26 which coincides with what we have reported
(33.3%).The main causes are related to pulmonary infection,
which in turn causes concomitant respiratory infections,
which would explain the high percentage of bacterial and
bilateral bronchopneumonia in our study. In more than 90%
of the autopsies carried out in patients with HIV, there is
pulmonary participation in the process which leads to death,6
a fact which we have also checked. In general, complications
and failures are to be expected after surgical treatment of
pneumothorax in patients with HIV.
Conclusions
– AIDS was most common in men in their thirties
– The main causes of pneumothorax were infections and
catheterisation of the subclavian vein
– Immunodeficiency had a relevant prognostic role in the
development and outcome of the patient
– Minimum pleurostomy continues to be the first treatment
224
Cir Esp. 2008;84(4):221-5
option in these patients due to their precarious general state
of well being which therefore contraindicates a more intense
procedure
– The most frequent complication was persistent air leak
which was a significant factor of bad prognosis in the patients’
development
– Acute respiratory insufficiency due to bilateral bacterial
bronchopneumonia and pleural sepsis were the main causes
of death
– Recommendation: catheterisation of the subclavian vein
should only be carried out as a last resort, after having
exhausted any other possibilities for venous access, due to
the high risk of pneumothorax and the serious complications
which can occur from the process
References
1. Da Ros CT, Schmitt Cda S. Global epidemiology of sexually transmitted
diseases. Asian J Androl. 2008;10:110-4.
2. Bartelsman M, Veeken H. The HIV pandemic in the year 2007, an
overview. Ned Tijdschr Geneeskd. 2007;151:2655-60.
3. de Arazoza H, Joanes J, Lounes R, Legeai C, Clémençon S, Pérez J,
Auvert B. The HIV/AIDS epidemic in Cuba: description and tentative
explanation of its low HIV prevalence. BMC Infect Dis. 2007;7:130.
4. Cabrera Cruz N, Toledo Fernández A. Los estudios de pesquisa activa
en Cuba. Rev Cubana Salud Pública. 2008;34:172.
5. de Arazoza H, Lounes R, Pérez J, Hoang T. What percentage of the
Cuban HIV-AIDS epidemic is known? Rev Cubana Med Trop.
2003;55:30-7.
6. Miller RF. HIV-associated respiratory disease. Lancet. 1996;348:
307-12.
7. Capó V, Arteaga E. Patrón de los hallazgos de autopsia en pacientes
cubanos fallecidos con la infección VIH/SIDA. VI Congreso Virtual
Hispanoamericano de Anatomía Patológica. Cuba, 1-31 marzo del
2004.
8. Spivak H, Keller S. Spontaneous pneumothorax in the AIDS population.
Am Surg. 1996;62:753-6.
9. Hoyt TL, Tarver RD. HIV, Pneumocystis carinii pneumonia, and
pneumothoraces. Semin Respir Infect. 2002;17:315-7.
10. Gassiot C, Pino P, Ramos M. Neumopatías asociadas al SIDA. Acta
Médica. 2000;9:73-89.
11. Afessa B. Pleural effusions and pneumothoraces in AIDS. Curr Opin
Pulm Med. 2001;7:202-9.
12. Martínez C, Seijas M, Ocampo A, López A, Oliveira I, Sopena B, et
al. Pheumothorax in patients infected by the human inmunodeficiency
virus. An Med Interna. 2001;18:521-4.
13. Miller RF, Allen E, Copas A, Singer M, Edwards SG. Improved survival
for HIV infected patients with severe Pneumocystis jirovecii pneumonia
is independent of highly active antiretroviral therapy. Thorax.
2006;61:716-21.
14. Morris A, Creasman J, Turner J, Luce J M, Wachter R M, Huang L.
Intensive care of human immunodeficiency virus – infected patients
during the era of highly active antiretroviral therapy. Am J Respir Crit
Care Med. 2002;166:262-7.
15. Aldrighetti L, Paganelli M, Arru M, Caterini R, Ronzoni M, Ferla G.
Complications of blind placement technique in 980 subcutaneous
infusion ports. J Vasc Access. 2000;1:28-32.
16. Reyes A, Díaz M, Pérez A. Tuberculosis y SIDA: algunos aspectos
clínicos y epidemiológicos en 72 enfermos cubanos. Rev Cubana Med
Trop. 2004;56:271.
17. García M, Pérez L, Franco F, Reyes G. Infecciones oportunistas
pulmonares en pacientes con infección por el virus de la
inmunodeficiencia humana del Instituto Nacional de Enfermedades
Respiratorias, 1991-2001. Rev Inst Nal Enf Resp Méx. 2003;16:6-10.
18. Shamsuddin K, Rosembaum D, Paul M, Bhojani R, Estrera A, Wait
M, et al. Surgical treatment of thoracic empyema in HIV-infected
patients. Severity and treatment modality is associated with CD4 Count
Status. Chest. 2005;128:246-9.
19. Wakai A, O’Sullivan RG, McCabe G. Simple aspiration versus intercostal
tube drainage for primary spontaneous pneumothorax in adults.
Cochrane Database Syst Rev. 2007;24(1):CD004479.
Cabrera-Cordero JA et al. Pneumothorax in Human Immunodeficiency Virus Infected Patients
20. Henry M, Arnold T, Harvey J. Pneumothorax. BTS guidelines for the
management of spontaneous. Thorax. 2003;58:48.
21. Tschopp JM, Rami-Porta R, Noppen M, Astoul P.Management of spontaneous
pneumothorax: state of the art. Eur Respir J. 2006;28:637-50.
22. Currie GP, Alluri R, Christie GL, Legge JS. Pneumothorax: an update.
Postgrad Med J. 2007;83:461-5.
23. Tan C, Sedrakyan A, Browne J, Swift S, Treasure T.The evidence on the
effectiveness of management for malignant pleural effusion: a systematic
review. European J Cardio-Thoracic Surg. 2006;29:829-38.
24. Barker A, Maratos EC, Edmonds L, Lim E. Recurrence rates of videoassisted thoracoscopic versus open surgery in the prevention of
recurrent pneumothoraces: a systematic review of randomised and
non-randomised trials. Lancet. 2007;370:329-35.
25. Treasure T. Minimal access surgery for pneumothorax. Lancet.
2007;370:294-95.
26. Vricella LA, Trachiotis GD. Heimlich valve in the management of
pneumothorax in patients with advance AIDS. Chest. 2001;120:
15-8.
Cir Esp. 2008;84(4):221-5
225